विवरण
Sepsis is a life-threatening complication of an infection which occurs when chemicals released in the bloodstream to fight an infection which trigger inflammation throughout the body.Many guidelines have been formulated for the treatment of sepsis in children and adults. These guidelines emphasize early recognition and aggressive treatment of the patient with sepsis in order to improve outcomes.
Join us in this coming up webinar with Dr Dharanindra Moturu, Lead Critical Care consultant at Aster Hospitals who will give an exclusive case based discussion on Septic shock and Surviving Sepsis guidelines.
सारांश
- Sepsis requires swift action, similar to stroke or myocardial infarction. Early identification and treatment are crucial for improving patient outcomes and reducing mortality. Delays in administering antibiotics can significantly increase the risk of death.
- The sepsis one-hour bundle is a key guideline to follow. It includes measuring lactate levels, obtaining blood cultures before administering antibiotics, administering broad-spectrum antibiotics, and rapidly administering intravenous fluids at a rate of 30 ml per kg body weight.
- Vasopressors can be started concurrently with fluid resuscitation if the mean arterial pressure is not maintained at 65 or systolic pressure isn't above 100 mmHg. A central line is not required to initiate vasopressor therapy. Early administration of antibiotics and vasopressors is crucial to prevent organ dysfunction and hyperperfusion.
- Broad-spectrum antibiotics should be chosen appropriately based on the clinical presentation. For instance, gram-negative coverage is preferred for acute abdomen, while gram-positive coverage is better for skin and soft tissue infections. The full dose of the antibiotic should be given initially, even in patients with renal failure.
- Normal saline has been phased out in favor of balanced crystalloids such as Ringer's lactate or Ringer's acetate. Baseline arterial blood gas (ABG) should also be taken.
- The emphasis on time management has increased in recent sepsis guidelines, shifting from six-hour and three-hour bundles to a one-hour bundle. In the absence of shock, antibiotics may be administered within three hours. However, antibiotic administration should not be delayed beyond one hour for patients in shock.
- Common barriers to sepsis bundle compliance include difficulty obtaining lactate levels and blood cultures. Ensuring access to ABG machines and having readily available blood culture materials are essential. Test doses of antibiotics are unnecessary in patients who are in septic shock.
- Fear of fluid overload should not deter the administration of 30 ml per kg of crystalloids. Hypoperfusion is more detrimental than fluid overload and can be managed. Monitoring dynamic hemodynamic indices, such as 2D echocardiography, can help guide fluid therapy.
- The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is essential. Thorough clinical examination, including often-missed areas like the groin and pelvis, is crucial for identifying the source of infection. Sepsis and septic shock are medical emergencies that require immediate intervention.
- Dynamic measures of fluid responsiveness, such as cardiac output measurements, can be used to guide fluid resuscitation. When crystalloid limits are reached, albumin can be considered. Hydroxyethyl starch should not be used. Norepinephrine is the first-line vasopressor. Vasopressin can be added if the norepinephrine dose exceeds 0.4 mcg/kg/min.
- Dobutamine can be used in cases of sepsis-associated cardiomyopathy. The target mean arterial pressure (MAP) is 65 mmHg. Source control, including bedside procedures when possible, should be implemented early. This can be as simple as I&D (incision and drainage) of an abscess at the bedside.
- Indwelling catheters suspected of causing sepsis should be removed.
- Hospitals are advised to implement performance improvement programs for sepsis and septic shock. The QSOFA score has been replaced by SIRS, NEWS, and MUSE for initial screening. However, the SOFA score still used for the organ dysfunction assessment. Lactate levels should be remeasured to assess the effectiveness of resuscitation.
- If sepsis is ruled out after initial evaluation, antibiotics should be de-escalated. When broad-spectrum antibiotics have already been administered, appropriate escalation may be warranted for MRSA, MDR organism or fungal infections. Optimize antibiotic dosing (infusion-based in certain situations), and ensure prompt removal of vascular catheters and access devices that are potential sources.
- Antimicrobial stewardship to prevent antimicrobial resistance is critical. The appropriate antibiotics that should be used may need to be limited and restricted to certain situations.
- Crystalloids are first line and albumin is a reasonable second line in septic shock when crystalloid resuscitation is deemed inadequate.
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